Women and HIV: Challenges and Opportunities - Kenya

1. Women and HIV: Challenges and Opportunities - Kenya Dr. Jemima Kamano Associate Program Manager, AMPATH Lecturer and Consultant Physician, Moi University School of Medicine and Moi Teaching and Referral Hospital www.ampathkenya.org

2. Map of Kenya Kenyan Statistics • Country population: 44,351,000 people • Women population: 50.11% • Life expectancy: 61 years • GDP per capita is US $1800, i.e. 82% lower than the world’s average. Population below poverty line: 45.9% • Prevalence of HIV: 5.6% • Prevalence of HIV in women: 6.9% • Prevalence of HIV in men: 4.4%

3. AMPATH • Academia and Government partnership • Started in 2001 in response to HIV • Restructured in 2009 to address population health • Currently taking care of 60,000 HIV positive patients, of whom 68% are women

4. Gladys • Married to a philandering husband at age of 21 • Not employed and no special skills • Husband, sole breadwinner, denied her permission to ever take a HIV test • Diagnosed HIV positive at ANC – 4th child • Disclosed status, beaten and abandoned by husband, family and in-laws • No income, 4 children, and expected to attend clinic, exclusively breastfeed, and eat healthy • Worst fear through all of this was: “what if my children are also infected?” Gladys at her workstation at AMPATH. Gladys giving a talk in one of the motivational sessions to patients in the psychosocial support group.

5. Jane • Jane, 45 years old. • HIV positive on ART for the last 15 years. • Widowed at 29 years, and raised her 4 children alone. • First born daughter got an early pregnancy from the sex for fish trade at age 12. • Jane recently had a minor stroke and was then diagnosed hypertensive – treatment unaffordable. • Jane has never had a pap smear, yet her two sisters have both been diagnosed with cervical cancer. She has lived in fear of any kind of screening. • Recently regained hope after joining a support and GISE group and now able to afford hypertension care since its integration in CCC.

6. Esther • Esther: 18 year old orphan. • Born with HIV and started ARVs as a child. • Grew up with step family, endured lots of abuse about having been promiscuous like her mother. • Due to the abuse, lost hope early and had very poor adherence in early teenage years – failed first line. • Now in college, on second line, biggest challenge: disclosure to peers, dating with HIV. • Her words: “I do fear what will happen when my second line finally fails, so I do all in my power to keep it working. But when the time comes, I know AMPATH will find a way for me, you already kept me for 18 years, and now am full of life and have so much to live for.”

7. Challenges • Women socio-economically and culturally disempowered and more stigmatized. • Limited access to healthcare: Health systems underfunded, static and geared to diseases rather than populations. • Limited access to capital, skills: Silo programs at national level and in healthcare • Little community involvement in funding and in planning. • Continued risky sexual behavior among especially younger women with continued spread and low access to screening. • Without community screening, higher rates of MTCT in community despite falling rates in hospitals. • HIV mortality rates still high, and resistance rates increasing. • Aging population with HIV hence increased NCDs that are now contributing immensely to the health burden but remain unaddressed.

8. Opportunities • Population health approach: Find, Link, Treat and Retain (FLTR): Early case and risk finding and intervention = control. • Integrated care task shifted/shared to the lowest primary care level; Care package that’s community centered. • LACE (Legal Aid Centre of Eldoret). • Population health supported by Zuri Health Insurance and AMPATH coordinated microfinance groups.

9. Expected outcomes from microfinance groups • Group caring for themselves • Improved linkage; target > 80% • Retention in care; target > 95% • Improved drug compliance/adherence • Improved quality of life • Cost reductions – patients & program • Economic gains for the group from activities OVERALL: Reduction in community VL & HIV incidence --– HIV pandemic control

13. MembershipFamily Preservation Initiative • Total of over 10,000 members ever enrolled in GISE • 83.33% female members • 75.01% attendance rate to group meetings • 98.8% retention rate • 13.3% average membership growth rate

14. Conclusion • Era of HAART may have brought new hope, but deeper socio-economic and systems issues still need to be solved. • Funding ≠ Access ≠ Utilization • Nothing can put women down forever, they always will bounce back and stronger. • Investing in women, the only way to ensure population health.

15. Acknowledgements • PEPFAR and USAID • Abbott • AbbVie • Eli Lilly and Company • Grand Challenges Canada • AMPATH Consortium • Kenya MOH • The great people of Western Kenya

16. Thank you